Analysis The Event The roller gravity davits suspending the port lifeboat were not in the locked position with the triggers set in place to hold the weight of the moveable boat/davit assembly. Consequently, the load was being taken by the winch/braking system and the lashing lines. As the bosun tried to secure the forward trigger line while sitting astride the davit cradle, the other seaman was trying to do likewise on the aft davit cradle. Realizing his line was too short to arm the trigger mechanism, the seaman descended the cradle by way of the welded rungs of the cradle ladder. When he descended the ladder, the lifeboat on its roller davits began to move down the cradle track. In the few seconds it took to realize what was happening, the lifeboat had already descended approximately half of its travel, knocking the bosun overboard. The winch brake did not automatically reset, and manual application of the brake to stop the lifeboat was too late. Although the seaman could not say with certainty whether or not he stepped on the brake lever extension during his descent of the ladder, the sequence of events and the fact that the brake lever extension was so close to the welded rungs of the ladder, point toward this possibility. The excessive play in the safety pin arrangement allowed the brake to disengage, and the lashing line that held the boat in place had ruptured as soon as the weight of the boat and roller davits came to bear upon it. Safe Operating Procedures The captain and crew had joined the vessel some two months earlier. Although the gravity davit system was similar to most other types, release mechanisms and davit configurations can differ. The on-board instruction manual for davit use was lacking in detail and poorly translated from the original Japanese. The lack of clear and accurate descriptions of the equipment and operating instructions was a contributing factor revealed in a recent U.K. Safety Study of lifeboat and launching system accidents.5 During the International Maritime Organization (IMO) Sub-Committee meeting on flag state implementation in April2002, numerous casualty reports were reviewed by the correspondence group on casualty analysis. One of the findings was that without proper guidance or encouragement in the use of easily understood and relevant manuals, crews are at greater risk of making errors of judgment and understanding. A recent IMO MSC circular reiterates this point, citing lack of familiarity with the equipment and design faults as factors contributing to accidents.6 National statistics from the U.K. show that 12lives have been lost in lifeboat accidents since1989.7 According to TSB data on lifeboat operations in Canadian waters, 14fatalities occurred over a similar period. On board the Kent, not only had the bosun placed himself in a dangerous position, he was undertaking a two-person task alone. Ideally, one person must hold the securing eye of the trigger line steady, while another arms the trigger line by swinging the trigger release arm up and parallel with the cradle arm, pinning it in place. Preferably, the person holding the securing eye should be in a safe position, clear of the davit cradle track, such as from a vertical ladder located at the side of the davit cradle, directly in the way of the trigger securing position. Equipment Malfunction The winch brake, although operable, was in poor condition. In particular, the auto-stop safety feature of the brake lever counter-weight did not work. Once the brake lever was lifted into the brake-off position, it stayed there, requiring additional physical force to re-engage the brake completely by depressing the lever (instead of the counterweight dropping into place by itself). The safety pin, which would normally prevent the brake lever from being released accidentally, was positioned in such a way that it did not provide a positive lock. The 12-mm gap allowed the lever to be moved enough to release the brake with the safety pin still in place. The steel wire cable lashing line was corroded well beyond its serviceable life. Although plastic protected wire cable can hide the condition of a steel wire, in this case, even a cursory inspection would have revealed the deteriorated condition of the cable. The failed cable, together with a similar piece of lashing from the starboard lifeboat davits, was examined by the TSB Engineering Branch8 (seephotos4and5). It was concluded that only 37percent of the steel wires within the port cable were carrying the load and 55percent were effective in the starboard cable. Severe corrosion caused the starboard cable to fail under testing at a load of 1638kg, and the port side would have likely failed at a load of approximately 1119kg. Photo5. Starboard lashing cable A copy of the TSB Engineering Report, LP089/2002, Failed Cable Examination - Lifeboat Lashing Lines - M.V.Kent, is available upon request. Most accidents are the result of several factors that combine to produce the event. The physical defences that were meant to protect the crew - davit winch brake, safety pin and lashing line - were disabled or seriously at fault. Consequently, the bosun was working in an unsafe environment. International Safety Management Code and a Safety Culture An interim International Safety Management Code (ISM) certificate had been issued only two months prior to the incident, providing a six-month period to allow full compliance with the code. Although the vessel possessed valid ISM certificates, there were several examples where the code or the intent of the code was not adhered to at the time of the accident. These include: Non-Adherence to Minimum Safe Manning Criteria. At the best of times, transiting the St.Lawrence Seaway, with its numerous lockage manoeuvres, is a demanding endeavour for the deck crew. Consequently, a vessel should always have its full complement during Seaway transit. Vessels can receive exemptions from the flag state to operate under the required minimum for short periods of time. This is an accepted practice and reflects operational realities. The Kent, although not operating under an exemption at the time of the accident, had five deck ratings and was, therefore, one person short of the required number at that time. Furthermore, the fifth deck-rated crew member had been assigned to engine-room duties, which left all deck duties for normal operations to be accomplished by the four remaining deck ratings. Although this practice does not contravene flag state rules, when combined with the already reduced crewing level, it effectively resulted in the vessel operating with two fewer deck ratings than the minimum specified in the MSM certificate in force at the time of the accident (or one fewer than the new MSM approved by the flag state on 30July2002). Any reductions below the minimum complement in one crew sector will adversely affect the rest periods of the remaining complement in that sector, leaving them susceptible to fatigue during intensive operations such as the successive locking and unlocking during a Seaway transit. Fatigue Awareness and Countermeasures. Although the company's safety and training manual gives great detail as to the effects of fatigue, no guidance is offered on how to realistically avoid fatigue given the intense operational pressures of Seaway transit and regular port-of-call duties - particularly in light of the fewer-than-minimum number of deck crew assigned. In the 24hours preceding the accident, the bosun had approximately four hours off duty, and his judgment, reaction time and alertness would have been adversely affected by fatigue. Repairs by Unqualified Personnel. The operation managers instructed the master to undertake repairs on the port davit using on-board resources while under way, in an attempt to avoid delaying the voyage by stopping for in-port repairs. When repairs to a specialized piece of equipment on a vessel are required, the manufacturer (or its representative) ought to be consulted as to the appropriate repairs/replacements required to restore the unit to its original state. Only special shore-based repair facilities have the equipment and skilled tradesmen to perform such work. In this case, without the precise alignment of the port davit cradle roller track and built-in sheave assembly, the efficient operation of the running rigging and roller gravity davits could not be guaranteed. Use of Non-Approved Equipment. The port davit and lifeboat were temporarily excluded from use as lifesaving equipment by DNV, until the davit could be repaired satisfactorily. Nevertheless, the master insisted, at Montral, that the defective port davit be tested by the crew for possible use in an emergency. Taken individually, each of the above examples did not directly contribute to the accident. Taken collectively, however, they can be considered to have appreciably increased the risk on board the Kent. The gap between the safety pin and its brake release lever, and the less-than-adequate maintenance on the brake-lever mechanism, contributed to the unexpected release of the lifeboat down the davit cradle. The wire rope used as the lashing line was in a severe state of corrosion and well beyond a serviceable state. The davit cradle ladder rungs were located in very close proximity to the faulty winch brake lever, and as the seaman descended the aft davit cradle, he probably stepped on the winch brake lever extension, instead of the ladder rung, and released the lifeboat. The ladder rungs only provided vertical access at the extreme outboard end of the davit cradle, compelling personnel to place themselves in a dangerous position on the inclined portion of the davit roller track when securing the lifeboat. With the davit winch brake disengaged, the corroded lashing line failed to hold the weight of the port gravity davits and the suspended lifeboat, allowing the assembly to slide down the davit cradle, knocking the bosun overboard.Findings as to Causes and Contributing Factors The gap between the safety pin and its brake release lever, and the less-than-adequate maintenance on the brake-lever mechanism, contributed to the unexpected release of the lifeboat down the davit cradle. The wire rope used as the lashing line was in a severe state of corrosion and well beyond a serviceable state. The davit cradle ladder rungs were located in very close proximity to the faulty winch brake lever, and as the seaman descended the aft davit cradle, he probably stepped on the winch brake lever extension, instead of the ladder rung, and released the lifeboat. The ladder rungs only provided vertical access at the extreme outboard end of the davit cradle, compelling personnel to place themselves in a dangerous position on the inclined portion of the davit roller track when securing the lifeboat. With the davit winch brake disengaged, the corroded lashing line failed to hold the weight of the port gravity davits and the suspended lifeboat, allowing the assembly to slide down the davit cradle, knocking the bosun overboard. The vessel Kent was operating with fewer than the minimum number of deck ratings required by the Minimum Safe Manning (MSM) certificate. Additionally, the practice of assigning ratings to duties other than those described in the MSM certificate undermines the criteria under which the MSM was issued. In the 24 hours preceding the accident, the bosun only had four hours off duty, and his judgment, reaction time and alertness would have been adversely affected by fatigue. The operating managers elected to have the crew attempt repairs on the port davit while under way to avoid delaying the voyage, rather than ensuring classification approval by having a specialized shore-based facility precisely re-align the port davit and restore it to its original state.Findings as to Risk The vessel Kent was operating with fewer than the minimum number of deck ratings required by the Minimum Safe Manning (MSM) certificate. Additionally, the practice of assigning ratings to duties other than those described in the MSM certificate undermines the criteria under which the MSM was issued. In the 24 hours preceding the accident, the bosun only had four hours off duty, and his judgment, reaction time and alertness would have been adversely affected by fatigue. The operating managers elected to have the crew attempt repairs on the port davit while under way to avoid delaying the voyage, rather than ensuring classification approval by having a specialized shore-based facility precisely re-align the port davit and restore it to its original state. The master insisted on using equipment that was neither safe nor class approved.Other Finding The master insisted on using equipment that was neither safe nor class approved. Safety Action Action Taken The operating managers sent a fleet-training superintendent on board to analyze the accident and carry out corrective training. Subsequent to this visit, certain design features of the lifeboat davits were modified, including the following: Permanent vertical ladders were installed under and beside the securing point of the trigger lines, thus giving direct but protected access to the trigger-line securing arrangement (seePhoto6). The existing cradle arm ladders were removed. Clearance between the winch brake release lever and its safety pin was removed, so that the lever cannot be moved when the pin is in place. Working procedures were established that require the lowering, recovery and securing of the lifeboat to be done with at least two persons and an officer present. A report of the incident was promulgated fleet-wide to provide information and stimulate feedback. The operating managers are in the process of amending the personnel recruitment section of the International Safety Management (ISM) manuals, so that particular attention is paid to crewing levels in relation to the MSM requirements of the flag state. The TSB is unaware of the actual state of these procedural modifications at this time. Safety Concern Minimum Safe Manning The issuance of a new MSM certificate by the flag state affirmed that the Kent had a full complement of qualified crew on board. The certificate included a minimum requirement of five deck ratings (previously assessed at six). However, one of the deck crew who had dual certified ratings was assigned to the engine room, leaving the remaining deck crew of four effectively understaffed. While the practice of re-deploying dual certified crew from one department to another does not contravene flag state rules, if such a practice has the effect of reducing one department below its specified number, it can have a serious impact on the safe operation of a vessel. This contradicts the fundamental premise under which an MSM certificate is issued. Flag states are responsible for evaluating and approving proposals submitted by vessel operators for establishing the minimum number of crew required for a particular vessel. International Maritime Organization (IMO) ResolutionA890(21), Principles of Safe Manning,is used to establish this number. However, there are no standard methods or formulae provided for actually quantifying the crew required. Nevertheless, a flag state must make a critical and objective assessment of crewing proposals for each particular ship with a given operational envelope. IMO ResolutionA890(21), Principles of Safe Manning, addresses statutory provisions, performance factors and on-board functions that should be taken into account during the assessment process. However, these principles and guidelines provide only a qualitative reference. In other industries, systems engineering methods have been used to quantify personnel needs. However, this methodology is not part of the IMOResolution. Port states regard compliance with the MSM certificate as evidence that vessels are safely staffed and that the use and deployment of the personnel listed will be as described therein. The St. Lawrence Seaway Management Corporation, in its Seaway Notice No.3-2004, mentions that vessels accepted with minimum crew must participate in the tie-up service with well-rested crew members. However, this is contingent upon the minimum crew being departmentally assigned in accordance with the MSM certificate. The TSB is concerned that the IMO's Principles of Safe Manningdo not provide sufficient rigour to the process of providing guidelines for the determination of proper ship crew size and the description of crew members' duties.